Public participation in healthcare students' education: An umbrella review

Abstract Background An often‐hidden element in healthcare students' education is the pedagogy of public involvement, yet public participation can result in deep learning for students with positive impacts on the public who participate. Objective This article aimed to synthesize published literature reviews that described the impact of public participation in healthcare students' education. Search Strategy We searched MEDLINE, EMBASE, ERIC, PsychINFO, CINAHL, PubMed, JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and the PROSPERO register for literature reviews on public participation in healthcare students' education. Inclusion Criteria Reviews published in the last 10 years were included if they described patient or public participation in healthcare students' education and reported the impacts on students, the public, curricula or healthcare systems. Data Extraction and Synthesis Data were extracted using a predesigned data extraction form and narratively synthesized. Main Results Twenty reviews met our inclusion criteria reporting on outcomes related to students, the public, curriculum and future professional practice. Discussion and Conclusion Our findings raise awareness of the benefits and challenges of public participation in healthcare students' education and may inform future research exploring how public participation can best be utilized in higher education. Patient or Public Contribution This review was inspired by conversations with public healthcare consumers who saw value in public participation in healthcare students' education. Studies included involved public participants, providing a deeper understanding of the impacts of public participation in healthcare students' education.

Inclusion Criteria: Reviews published in the last 10 years were included if they described patient or public participation in healthcare students' education and reported the impacts on students, the public, curricula or healthcare systems.
Data Extraction and Synthesis: Data were extracted using a predesigned data extraction form and narratively synthesized.
Main Results: Twenty reviews met our inclusion criteria reporting on outcomes related to students, the public, curriculum and future professional practice.
Discussion and Conclusion: Our findings raise awareness of the benefits and challenges of public participation in healthcare students' education and may inform future research exploring how public participation can best be utilized in higher education.
Patient or Public Contribution: This review was inspired by conversations with public healthcare consumers who saw value in public participation in healthcare students' education.Studies included involved public participants, providing a deeper understanding of the impacts of public participation in healthcare students' education.

K E Y W O R D S
curriculum, healthcare education, patient-public engagement, research synthesis

| INTRODUCTION
The pedagogy of public involvement is an approach used to engage members of the public to actively participate in decision-making around issues that affect their lives and communities.The aim is to empower individuals and communities with the knowledge, skills and opportunities to participate in or contribute to these decisions. 1phasis is often placed on inclusivity, transparency and collaboration to foster partnerships between decision-makers and the public. 1,2In the context of healthcare students' education, the pedagogy of public involvement focuses on engaging patients, families and communities in teaching healthcare students.
Historically, patient involvement in teaching healthcare students has been a cornerstone of learning, where patients engage as storytellers or resources for students.However, over time this has evolved. 3,4Recently, there has been a need to develop this involvement further towards an emerging pedagogy of public involvement throughout educational programmes. 2,3Modigh et al. 5 argued that this shift is a moral responsibility and that those who pay for and/or receive healthcare ought to inform how it is provided.This emerging pedagogy holds promise to impact students, the public, educational curricula and healthcare systems.Public involvement emphasizes patient-centred care and acknowledges the expertise and perspectives of patients and their families. 1,2,6It can promote the active involvement of patients and families in their own care, encourage shared decision-making and foster the development of patient advocacy skills. 1,4The pedagogy of public involvement in healthcare students' education can also enhance empathy, 7,8 communication skills, 9 reflective practices and critical thinking that encourages students to critically examine power dynamics, social inequities and ethical considerations in healthcare.Additionally, it has benefits for patients such as empowered participation in their own care, 6 and feeling like they have contributed to others. 10Integrating the principles of public involvement into healthcare education may result in more patient-centred, community-oriented and socially responsible healthcare systems.
The pedagogy of public participation incorporates patient and public involvement across multiple touchpoints in healthcare students' education programmes.Patient involvement range includes little involvement, emerging involvement, growing involvement, collaboration or partnership. 2,4,11While some promising evidence continues to emerge regarding the impact of public involvement in healthcare students' education, the literature lacks coherent, evidence-based direction for how public participants, students and educators can best enhance teaching and learning experiences and ultimately improve healthcare experiences for all.Therefore, this umbrella review aimed to identify current, relevant and robust evidence on the impacts of public participation in healthcare students' education on students, public, curricula and healthcare systems.

| Design
In conducting our umbrella review, we followed best practices as outlined by the Centre for Reviews and Dissemination (CRD) 12 and the Joanna Briggs Institute (JBI) guidelines for systematic reviews and research syntheses. 13While the JBI and CRD recommend that only systematic reviews be included in umbrella reviews, we purposefully included all types of reviews in our analysis.

| Data sources and search strategy
An experienced librarian reviewed our literature search strategy in November 2022.We searched the following databases to identify English language reviews suitable for inclusion in this review: MEDLINE, EMBASE, ERIC, PsychINFO, CINAHL, PubMed, JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects and the PROSPERO register.A complete search strategy for all included databases can be found in Table S1.

| Eligibility criteria
Reviews were included if they: 1. focused on healthcare students, patients/public and/or healthcare educators; 2. described patient or public participation in healthcare students' education; 3. reported on the impact of patient/public participation in healthcare students' education, including impacts on students, patient/public, curricula or healthcare setting and 4. were published from 2012 onwards.
Reviews were excluded if they: 1. focused on non-healthcare students or non-healthcare educators; 2. did not address the patient/public participants in healthcare students' education; 3. were primary studies, commentaries, editorials or letters; 4. had not been published within the last 10 years and 5. were non-English language reviews.

| Selection of reviews
All search results were exported to Covidence to facilitate data management, organization and progress of this review.Studies were screened in two stages.First, study titles and abstracts were independently screened in duplicate by two reviewers.Screeners achieved an overall interrater agreement above 90% and all disagreements were resolved by a third reviewer.Second, full texts of studies included during title and abstract screening were subsequently screened in the same manner as title and abstract screening.

| Quality appraisal
The reviews that met the inclusion criteria were assessed independently by two researchers using the Joanna Briggs Institute's Critical Appraisal Checklist for Systematic Reviews and Research Synthesis 13 with disagreements resolved through discussion.The checklist includes 11 assessment criteria that were each scored 'yes', 'no', 'unclear' or 'not applicable'.We did not exclude reviews based on their quality appraisal scores.

| Data extraction and synthesis
One reviewer independently extracted data from the included reviews and a second reviewer reviewed the extraction data for accuracy.Any disagreements in extraction were resolved through discussion.Due to the heterogeneity of the reviews, a meta-analysis was not possible.We instead utilized a narrative synthesis approach to describe the impact public participation in healthcare students' education has on students, the public, curricula and healthcare systems.

| RESULTS
Our electronic and hand searches generated 2564 records, which were screened for inclusion and 30 underwent secondary full-text screening.Of these, 20 reviews were included in the final synthesis.
Figure 1 displays the flow of literature throughout our review.

| Review characteristics
Table 1 provides an overview of review characteristics.The included reviews were published between 2012 and 2022 with nine (45%) published since 2020.A wide range of studies were included in the reviews, with a minimum of 7 studies and a maximum of 59 studies assessed in a single review.When combined, a total of 49,014 articles were screened within the included literature reviews, and 418 were selected for synthesis.Most review articles reported sufficient information across most of the criteria; however, some authors failed to report whether the appraisal of studies included in the review was conducted independently by at least two authors; how or if data from the studies were systematically extracted, and how authors combined included studies in their results.

| Reported outcomes
Table 3 presents a high-level overview of study characteristics, Table 4 presents items related to review findings and Table 5 presents the key themes identified within the extracted data.The following narrative synthesis presents reported outcomes related to the impact on students, the public, healthcare and curricula.

| Impact on students
Of the 20 articles included in this review, all reported the impacts of public participation in healthcare students' education on students.

| Increased awareness of patient's perspectives and experiences
[25][26][27][28][29]31,32 For some, this awareness led to a reduction in the stigmatization of certain conditions such as mental illness.As a result of interacting with the public, students reported an increase in their awareness of patients' experiences with a variety of medical conditions.Interestingly, no articles reported on unconscious bias.

| Greater empathy
24]32 By speaking with patients about their perspectives and experiences, students developed a greater awareness and empathy for a variety of challenges patients may face.

| Self-reflection and personal growth
Student self-reflection and personal growth were identified in four articles as impacts of public participation in healthcare students' education. 16,20,27,32Khalife et al. 20 explained that self-reflection following interactions with the public allowed healthcare students to accept patients' needs and improve as practitioners.Scammell et al. 27 identified that patient interactions followed by selfreflection gave healthcare students better insights into their goals and future careers.

| Increased confidence in supporting patients
Eight articles discussed the impacts of public involvement in healthcare students' education on developing students' confidence to support patients. 15,17,22,24,26,29,31,32When given the opportunity to work with members of the public, students utilized skills they learned throughout their education in real-world settings.This increased their overall confidence in their ability to provide competent and supportive care to serve the needs of their patients. 14

| Greater ability to address stigma and discrimination
23][24]32 Arblaster et al. 32 discussed the many forms of stigma people face, such as mental health issues, poor or unequal living circumstances and adversity to recovery, and suggested students can address stigma and discrimination by supporting social inclusion, challenging stigmatizing attitudes, F I G U R E 1 Flow of literature through the umbrella review.
promoting positive understandings of peoples struggles and partnering with communities.Community engagement and exposure to the patients' struggles provide students with some knowledge and experiences to address stigma and discrimination.

| Impact on the public
Sixteen of the 20 articles reported outcomes of the impact of public participation in healthcare students' education on the public.

| Empowered to be more active in care
9,32 Engaging with healthcare students resulted in the public developing an increased sense of empowerment to be more involved in making medical decisions.

| Increased trust in healthcare providers
20 3.5.3 | Shared deion-making and collaborative care 8]20,28,30,32 Shared decision-making can empower patients when they are consulted within their care. 16Arblaster et al. 32 explained that public consumers of healthcare feel supported and empowered by collaborative care approaches and being involved in students' education.

| Decreased stigma and discrimination
Five articles reported on how public participation in healthcare students' education impacted public experiences of stigma and discrimination. 18,21,29,30,32The decline of stigma and discrimination was described previously regarding its impact on students; however, this was also identified as an impact on the public.Arblaster et al. 32 acknowledged that the most common outcome of consumer participation in healthcare education was a decrease in stigma.Public involvement in education actively decreased the stigma and discrimination against members of the public because healthcare students learned how to consider patient perspectives during their education.

| Enhanced understanding of recovery
Three articles reported that when patients interacted with healthcare students, patients developed an enhanced understanding of their recovery. 4,27,32Public participation in healthcare students' education contributed to moving to recovery-orientated practice specifically for those with mental health concerns. 32

| Increased mental health and quality of life
Two articles reported on how patient participation in healthcare students' education resulted in patients having an increased sense of mental health and quality of life. 28,32Mental health needs to be more readily addressed within healthcare, and public involvement in education may be one way to address this need.When students developed skills to hear and respond to patients and their experiences, patients felt well taken care of and not discouraged or hindered by their mental health.However, these benefits were not universal.Terry 28 reported that patient engagement in healthcare students' education was stressful. 28

| Potential impact on healthcare
Sixteen out of 20 reviews included in this study highlighted the potential impact that public participation in healthcare students' education has on healthcare more broadly than just on individual patients and students.

| Collaboration between patients and healthcare providers
Seven articles reported on the potential of public participation in healthcare students' education to increase collaboration between patients and healthcare providers more broadly. 4,14,16,19,20,25,32rdon et al. 4 found that the collaboration between patients and healthcare providers had the potential to improve healthcare overall.

| Better healthcare service based on consumer participation
20]32 Patient views of the impact of being involved in the education of healthcare students included personal fulfilment in the belief they were improving the healthcare system. 14Others reported the involvement of patients led to improved outcomes 15 and an increased understanding of patientcentred 4 holistic care, 32 potentially impacting healthcare services.

| Increased accountability and transparency
The theme of accountability and transparency was present in one article.
Arblaster et al. 32 took a comprehensive view regarding accountability and transparency within a patient-worker collaborative model and found where patients were teaching and advising on their health to students it allowed for younger patients to be heard by those who are usually in a place of power.When patients are more involved in their care, healthcare providers can have a higher sense of accountability to ensure they share knowledge and account for the patient's perspective. 326.| 11 of 28 increased satisfaction.4,[15][16][17][18]20,23,24,26,32 When patients participated in teaching, healthcare providers learned patient-centred care and holistic care. The overall increase in patint satisfaction with their care allows greater confidence in healthcare systems potentially making healthcare better all around.

| Consumer-informed healthcare policies
Eight articles reported that when the public participates in healthcare students' education, this can potentially lead to more consumer-informed healthcare policies. 15,20,21,24,25,27,29,32The combined effort of patients and providers to create and influence new policies is notably beneficial.Perry et al. 25 addressed that a large interest has been placed on policy creation through a collaborative model with users of healthcare.Further, Scammell et al. 27 indicated that in places like the UK nursing policy development often involves engagement with healthcare users for advisement and recommendations.

| Decreased healthcare disparities
Five articles reported the potential of public participation in healthcare students' education to help decrease healthcare disparities. 15,16,18,19,32Dijk et al. 14 highlighted that Indigenous patient populations, transgender health and cancer disparities were better understood because of patient engagement in education. 14Notably, the participation of mental health patients in the education of healthcare students helped challenge stigma and discrimination, thus promoting social inclusion and positive understandings. 32

| Considerations for curriculum
Of the 20 articles included in this review, 12 reported on future curriculum considerations for public participation in healthcare students' education.

| Integrating patient perspectives into education
20][21]32 Integration of patient narratives and perspectives into students' education can advance student learning. 14For example, involving patients' lived experiences in mental health nursing education facilitated a new level of understanding for students. 20However, studies have identified the need for future research to determine the theoretical mechanisms through which patient involvement promotes learning. 31Another way in which patient perspectives may be integrated into education is the involvement

Medicine
To identify the scope of active patient involvement in medical education, the current knowledge gaps relating to rationale and motivation for involvement, recruitment and preparation, roles, learning outcomes and key procedural contributors.• Empowerment of patients in contributing to the assessment process and shaping the education of future healthcare professionals • Increased trust and confidence in healthcare providers knowing that their perspectives are valued in assessment • Improved understanding of consumers' perspectives and experiences with a positive change in beliefs and attitudes • Increased empathy and compassion towards mental health consumers (reduction of negative stereotypes, seeing patients holistically) • Enhanced communication and therapeutic skills • Some reported an increase in anxiety or worry Potential future impact on healthcare: • Enhanced awareness of equality, fairness and partnership Considerations for curriculum: • Integration of consumer perspectives into educational content enhanced the education experience (student perception) • Increased awareness of power imbalance and the need for partnership in practice Considerations for curriculum: • Increased cognitive dissonance and understanding of feelings of powerlessness that service users have • Report of student viewing service users as unqualified to teach and not as good as learning from teachers • Important not to over-emphasize a single experience when using service user involvement of patients in learner assessment.However, some barriers may influence such involvement, including language and reading comprehension challenges and the nonreadiness of educational programmes to partner with patients. 19To benefit from patient perspectives in education, such barriers require addressing.

| Embedding consumer-led initiatives into the curriculum
][19][20][21]32 Consumer participation across the design, planning and delivery stages of education, including serving as a learning resource, being a collaborator, assessing learning or helping with the development of teaching materials, with patients objecting to voyeurism and tokenism. 32Finch et al. 16 found that when patients give feedback on students' clinical skills it has a positive impact on learning.

| Incorporating real-life case studies into learning
24]32 Dijk et al. 15 explained that while simulations or practice with an inanimate body is useful, practice on real patients often results in more authenticity in care and provides better guidance with skills such as physical examinations.McCray et al. 23 reported on the positive impact on student academic performance through the incorporation of student-run clinic experiences in medical education.The use of patients as simulated patients has been reported in various healthcare professions education contexts such as with student pharmacists. 24

| Utilizing patient-centred teaching strategies
19,20 The rationale of exposing students to patient voices is to support the development of patient-centred professional identity and the understanding of patient-centredness. 14,15 Gordon et al. 4 took an in-depth look into the outcomes of utilizing teaching strategies that involve putting the patient first and suggested benefits to learners, such as a greater understanding of holistic and patient-centred care.Khalife et al. 20 advocated for a competency-based medical education framework that mandates students be exposed to patient-centred education to prepare them to meet the patient's needs.

| Promoting patient advocacy and professionalism
The promotion of patient advocacy as a part of professionalism was present in three articles. 16,20,32Arblaster et al. 32 reported that personal contact of healthcare students with mental health patients under power-equalizing conditions was key to stigma reduction and advocating for this patient population.
Khalife et al. 20 reported that patient involvement in assessment approaches in competency-based education could enhance learner advocacy competencies.

| Incorporating patients as teachers
The concept of incorporating patients as teachers was present in one article. 4Gordon et al. 4 highlighted that the involvement of patients as educators benefited students, including increased confidence and comfort working with patients; it also benefited patients as they felt they made a valuable and meaningful impact on healthcare.Further, Gordon et al. 4 stated that using patients as teachers is most effective when standardized assessment checklists and scoring criteria are clear.

| Including recovery-oriented practices
Our review identified recovery-oriented practices in two articles. 18,32Arblaster et al. 32 evaluated evidence regarding the effectiveness of patient participation in producing graduates with the ability for recovery-oriented occupational therapy practice; although the authors cautioned that minimal evidence currently exists, they highlighted that patient participation is a way to exemplify recovery-oriented practice and that education should continue to involve patients.Happell et al. 18 provide similar findings as they suggested that the consistent involvement of educators and patients within healthcare students' education allows students to gain a better understanding of multiple ways and paths of recovery.

| Enhancing cultural competence
Six articles reported the importance of enhancing cultural competence in healthcare students' education. 4,15,18,19,21,32The enhancement of cultural competencies has played a more vital role in recent years as healthcare and several other industries strive to diversify and understand diversity more readily.Dijk et al. 15 stated that one of the rationales for involving patients in medical education is the multicultural learning environment it produces that allows students to practice social accountability and inclusion.

••••••••••Medicine 1 . 2 .••
Increased engagement and motivation • Enhanced communication and interpersonal skills • Improved understanding of patient perspectives and experiences • Increased confidence in clinical decision-making • Development of teamwork and collaboration skills Impact on patients/public/consumers: • Improved patient satisfaction and experiences • Increased trust and collaboration between patients and healthcare providers • Better adherence to treatment plans and shared decision-making • Enhanced patient safety • Empowerment of patients in managing their own healthcare Potential future impact on healthcare:• Enhanced quality of care through improved patient-provider relationships • Promotion of patient safety and reduction in medical errors • Increased patient engagement and shared decision-making • Promotion of patient-centred care as a standard practice • Development of healthcare professionals who are responsive to patient needs and preferences.Considerations for curriculum: Integration of patient perspectives and feedback into curriculum design • Promotion of patient-centred care as a core principle • Increased emphasis on communication and interpersonal skills training • Development of cultural competency and understanding of diverse patient populations • Incorporation of real-life clinical scenarios and patient narratives in teaching T A B L E 4 (Continued) Enhanced patient experiences and satisfaction in mental health services • Increased collaboration and partnership between mental health professionals and service users • Promotion of shared decision-making and self-determination in treatment planning • Empowerment of mental health consumers in their own care • Reduction in stigma and discrimination through improved understanding and interaction Potential future impact on healthcare: • Improved quality of mental health services through person-centred and recovery-oriented approaches Increased engagement and satisfaction amongst mental health consumers • Reduction in treatment disparities and increased access to appropriate care • Promotion of recovery and well-being outcomes for mental health service users • Development of mental health professionals who are responsive to consumer needs and preferences Considerations for curriculum: Integration of mental health consumer perspectives into curriculum design • Promotion of recovery-oriented principles as a core component of education • Incorporation of lived experience narratives and consumer-led teaching methods • Development of skills in trauma-informed care and cultural sensitivity • Enhancement of interprofessional collaboration and teamwork skills [19] Medicine To systematically review published work that has explored terminally ill patient's views about being involved in undergraduate medical Increased understanding of the experiences and perspectives of terminally ill patients • Improved communication and empathy skills specific to end-of-life care • Enhanced ability to provide compassionate and patient-centred care • Development of skills in discussing difficult topics and delivering sensitive information • Increased awareness of the psychosocial and emotional aspects of end-of-life care Impact on patients/public/consumers: • Empowerment of terminally ill patients in sharing their experiences and contributing to medical education Increased trust and confidence in healthcare professionals through student engagement • Enhanced communication and relationship-building between patients and healthcare providers • Potential for improved end-of-life care and support • Promotion of patient advocacy and shared decision-making Potential future impact on healthcare: • Improved quality of end-of-life care through increased student exposure and education • Promotion of patient-centred and compassionate approaches in terminal illness management • Enhanced communication and collaboration between healthcare providers and terminally ill patients Development of healthcare professionals who are sensitive to the needs and preferences of patients at the end of life Potential for reduced disparities and improved access to palliative and hospice care services Considerations for curriculum: Integration of terminally ill patients' perspectives into curriculum design • Promotion of patient-centred and palliative care as essential components of medical education • Development of skills in discussing end-of-life care options and goals of treatment • Incorporation of ethical considerations and decision-making frameworks in terminal illness • Enhancement of cultural competency and understanding of diverse beliefs and practices related to death and dying [20] What is the extent, nature and range of literature that exists exploring patient involvement in the assessment of postgraduate medical learners?What factors appear to influence (e.g., affordances and barriers) patient involvement in competency-based assessmentEnhanced understanding of patient perspectives and experiences in their own learning and assessment Improved communication and interpersonal skills through interactions with patients • Increased awareness of patient-centred care and the importance of patient input in assessment • Development of empathy and professionalism in working with patients • Promotion of reflective practice and self-assessment skills Impact on patients/public/consumers:

Table 2
presents the quality appraisal assessment for all included reviews.
Increased awareness and understanding of mental health issues • Improved empathy and attitudes towards individuals with mental health challenges • Enhanced communication and interpersonal skills • Greater self-reflection and personal growth • Heightened awareness of the social determinants of mental health • Elevated confidence in providing support to individuals with mental health challenges • Enriched ability to address stigma and discrimination Impact on patients/public/consumers: • Increased empowerment and active involvement in their own care • Improved trust and rapport with healthcare providers • Enhanced shared decision-making and collaborative care • Reduced stigma and discrimination towards individuals with mental health challenges • Greater understanding and recognition of recovery-oriented practices • Improved mental health outcomes and quality of life Potential future impact on healthcare: • Improved collaboration and partnerships between mental health consumers and healthcare professionals • Enhanced service planning and delivery based on consumer feedback and preferences • Increased effectiveness of mental health services through consumer participation • Greater accountability and transparency in mental health systems • Improved quality of care and patient satisfaction • Enhanced policy development and implementation based on consumer perspectives • Reduced healthcare disparities and improved access to mental health services Considerations for curriculum: • Integration of consumer perspectives and experiences into educational programmes • Inclusion of recovery-oriented principles and practices in mental health curricula • Emphasis on person-centred care and shared decision-making • Enhanced focus on cultural competence and addressing health disparities • Incorporation of consumer-led initiatives and advocacy into the curriculum • Integration of real-life case studies and consumer narratives into teaching materials Abbreviations: EMR, Electronic Medical Records; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RAG, red, amber, green.T A B L E 4 Summary of review findings.
Improved quality of healthcare through the inclusion of patient perspectives in the assessment of learners • Enhanced patient safety by fostering a culture of continuous learning and improvement • Increased patient satisfaction and experiences through the involvement of patients in shaping future healthcare professionals • Promotion of patient-centred care as a standard practice in healthcare settings • Development of healthcare professionals who are responsive to patient needs and preferences.Considerations for curriculum: • Integration of patient involvement in assessment methods and processes • Development of patient-centred assessment criteria and tools • Enhancement of communication and interpersonal skills training in the curriculum • Incorporation of patient feedback and perspectives in curriculum evaluation and improvement • Promotion of professionalism and patient-centred care as core values in medical education